NURSING CARE

1.Assessment - Nursing Care Plan

1. History of diseases
Fever, cough, anorexia, history of respiration disease, insomnia.
2. Physical signs
Fever, dyspnoea, takypnoea, Dry skin with poor turgor, Breathing fast (tachypnea) and
shallow accompanied nostril, Breathing using accessory muscles, weight loss,
3. Growth factor
Generally, coping mechanisms, ability to understand the action, daily habits, level of
development.
4. Knowledge of patients or family
Experience respiratory diseases, respiratory disease and knowledge about the action
taken.
2. Nursing Diagnosis
1. .Ineffective Airway Clearance related to inflammation, the accumulation of secretions
characterized by Cough with sputum production.
2. .Impaired Gas Exchange related to alveolar capillary membrane
3. Hyperthermia related to inflammatory processes
4. Risk for infection related to inadequate secondary defenses (descrease hemoglobin,
hematocrit and immunosuppression)
5. Imbalanced Nutrition Less Than Body Requirements related to the lack of oral intake
characterized by Decreased appetite
6. Fluid Volume Deficit related to inadequate oral intake, fever, tachypnoea.
7. Intolerance activity related to imbalance between supplay and demand of oxygen, and
general weakness.
3. Nursing Interventions
1. Nursing Diagnosis 1
Ineffective Airway Clearance related to inflammation, the accumulation of secretions
characterized by Cough with sputum production
Goal: after do nursing action, the patients respiration will improve and difciculty of
breathing will be relieved, with outcome:
a. Respiratory Rate 20-24x/m
b. Narrow (-)
c. Airway respiration is clean
d. Cough (-)

e. Patient can put out sputum